Transoral thyroid and parathyroid surgery via the vestibular approach-a 2020 update

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Review Article

Transoral thyroid and parathyroid surgery via the vestibular
approach—a 2020 update
Jonathon O. Russell1, Zeyad T. Sahli2, Mohammad Shaear1, Christopher Razavi1, Khalid Ali1, Ralph P. Tufano1
1
Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Department of
Surgery, The University of Virginia Health System, Charlottesville, VA, USA
Contributions: (I) Conception and design: RP Tufano, JO Russell, M Shaear; (II) Administrative support: RP Tufano; (III) Provision of study materials
or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing:
All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Ralph P. Tufano, MD, MBA, FACS. Division of Head and Neck Endocrine Surgery - Department of Otolaryngology-Head and
Neck Surgery at The Johns Hopkins Hospital, 601 N Caroline St 6242, Baltimore, MD 21287, USA. Email: rtufano@jhmi.edu.

Abstract: Transoral endoscopic thyroidectomy and parathyroidectomy via the vestibular approach (TOET/
PVA or TOETVA-TOEPVA) is the latest remote-access technique employed in the central neck. As the
only approach that does not leave any cutaneous incision, (TOET/PVA) has become popular in both the Far
East and Western series since its original description in 2015. More than just a “scarless” surgery, (TOET/
PVA) has been associated with a short learning curve, access to the bilateral central neck compartments, few
surgical contraindications, minimal complications, and minimal additional instrumentation. To date, more
than 2,000 cases have been completed, including more than 400 in North America, demonstrating brisk
utilization of a novel technique relative to earlier remote access central neck approaches. Herein, we describe
updates that continue to improve the safety and efficacy of the procedure.

Keywords: Thyroidectomy; parathyroidectomy; thyroid surgery; TOETVA; TOEPVA; remote-access thyroid
surgery; scarless thyroid surgery; transoral thyroid surgery

Submitted Jan 24, 2020. Accepted for publication Feb 17, 2020.
doi: 10.21037/gs.2020.03.05
View this article at: http://dx.doi.org/10.21037/gs.2020.03.05

Introduction the ability of patients to achieve optimal cosmesis (5-7).
Before (TOET/PVA), remote-access thyroid and
For more than 100 years, thyroid surgery has been safely
parathyroid surgery techniques have succeeded in avoiding
performed via an anterior neck incision (1). This scar heals
an anterior neck incision by relocating the cutaneous incision
well in the majority of patients, with generally acceptable
to less conspicuous locations. Common examples include
cosmetic outcomes. Despite this, nearly 20% of patients will
experience some feelings of self-consciousness years after areolar or axillary incisions, which can effectively minimize
thyroid surgery, while more than 10% will consider further the cosmetic burden in some patients. Despite the improved
treatments such as plastic surgery to improve the appearance local cosmesis, these techniques may be challenging due to
of their scars (2). The impact of a cervical incision on the unfamiliar dissection planes, longer routes to the central
health related quality of life (HRQOL) was found to be neck, and novel complications. Additionally, a steep learning
similar to the impact of vitiligo, psoriasis, or severe atopic curve has been demonstrated, with long initial operative
dermatitis in one series (3). Because excellent cosmesis times (4). Consequently, the adoption of these alternative
cannot be guaranteed, remote-access thyroid surgery has techniques was slow, especially in the West (4).
evolved to address the potential morbidity of an anterior In 2016, Anuwong published the first case series of
cervical incision (4). Unfortunately, the perception of a scar 60 patients who underwent scarless thyroidectomy via the
can vary between patients and surgeons, further impairing lower vestibule of the mouth with excellent outcomes (8).

410 Russell et al. TOETVA/TOEPVA 2020 update

Table 1 Johns Hopkins’ TOETVA inclusion and exclusion criteria
Inclusion Exclusion

History of hypertrophic scarring or motivation to avoid an anterior Poorly differentiated cancer or anaplastic. Involvement of
cervical incision central neck, lateral neck, or extrathyroidal disease extension

Thyroid diameter ≤10 cm or thyroid volume ≤45 mL Unable to tolerate anesthesia or patient unfit for surgery

If benign/indeterminate nodule, ≤6 cm or dominant nodule ≤2 cm if Preoperative RLN paresis
Bethesda V/suspicious or confirmed differentiated thyroid cancer

Substernal goiter, grade 1 or Graves’ disease that is controlled with Prior trans-cervical neck surgery
medical management

Oral abscess
TOETVA, transoral endoscopic thyroidectomy vestibular approach.

This came as a result of worldwide efforts to explore exclusion criteria in the literature. Current TOETVA inclusion
an alternative remote-access thyroidectomy approach, and exclusion criteria of our practice are described in Table 1.
specifically by utilizing natural orifice transluminal TOETVA is intended for carefully selected patients.
endoscopic surgery (NOTES) concepts (9-14). The first Primarily, candidates must be motivated to avoid an
attempts were discouraging, as the sublingual approach anterior cervical scar and/or have a history of hypertrophic
resulted in devastating adverse effects, including hypoglossal scarring or keloids. Indications for TOETVA include both
nerve injury (15,16). Subsequently, Richmon et al. utilized benign and malignant conditions. Symptomatic grade I
the oral vestibule as an alternative to the sublingual goiter (anterior mediastinum) and Grave’s disease can be
approach (12) which was ultimately adopted by Anuwong. approached through TOETVA (36). Specific inclusion
Following the initial series, multiple institutions around criteria for thyroid preoperative ultrasonography size
the world have adopted this new technique with similar and volume and index nodule size vary between different
results (17-32). Currently, TOETVA, with approximately institutions and authors. Thyroid gland size cutoffs include
900 reported cases, perhaps more than other remote-access a diameter of 8–10 cm (8,37,38) or estimated thyroid
techniques, is attracting patients who are interested in volume ≤45 mL, with a nodule size cutoff between 4–6 cm
avoiding a neck scar (17,33). In the West, the endoscopic among benign or cytologically indeterminate (Bethesda II,
approach far exceeds the robotic approach, as the latter III, IV) nodules (30,31,39). For patients with nodules that are
requires extended operative time, a longer learning curve suspicious for malignancy (Bethesda V) or confirmed well-
and, occasionally, an axillary incision for the fourth arm of differentiated thyroid cancer without evidence of metastasis,
the robot (24). This manuscript aims to update the reader a maximum index nodule size of 2 cm has been utilized,
on the status of transoral thyroid and parathyroid surgery which has been shown to be a safe threshold (36,40). If
via the vestibular approach. completion thyroidectomy is necessary, a repeat-TOETVA
for the contralateral thyroid gland can be safely performed
within 3 weeks. After that window, it may be appropriate to
Indication and contraindications consider completion TOETVA after 6 months (41,42).
TOETVA Current TOETVA exclusion criteria include lateral neck
or extrathyroidal disease extension, pre-operative RLN
TOETVA surgical indications and contraindications have paresis, prior trans-cervical neck surgery, oral abscesses,
evolved since its first description in patients by Anuwong in or patient intolerance to general anesthesia. Previous
2016 (8) and are largely practice or institution specific (34). transoral neck surgery and neck radiation are not absolute
Fifty-five percent of patients undergoing thyroid and contraindications (37,43). Patient age or body mass index
parathyroid surgery—approximately 150,000 patients in the (BMI) are not absolute contraindications to surgery.
US—are estimated to be eligible for transoral endocrine
surgery using the most widely accepted guidelines (35). In this Surgeon candidacy
section, we will describe the current TOETVA inclusion and In addition to careful patient selection, surgeon candidacy is

Gland Surgery, Vol 9, No 2 April 2020 411

of utmost importance for procedure safety. Prior to learning Surgical steps and perioperative consideration
(TOET/PVA), a surgeon must be proficient in the standard
Perioperative considerations
procedures of the central neck, including thyroidectomy,
parathyroidectomy, and central neck dissection in case of After confirming eligibility for transoral thyroid surgery, the
necessary conversion to an open (standard) approach (44). patient should be aware of all the potential outcomes of the
High volume (bare minimum is more than 25 thyroid procedure, including numbness of the lower lip and chin.
surgeries per year) surgeons have significantly improved We also stress that the subcutaneous scar tissue will induce
outcomes and decreased costs in comparison to low volume mild symptoms of dysesthesia for some time in the midline
surgeons (45,46) with conventional cervical thyroidectomy, chin. Additionally, we stress the possibility of conversion
and an adequate volume is required to overcome the learning to an open technique if deemed appropriate to ensure
curve with any new technique. A study by Razavi et al. safety of the patient and completeness of the procedure, as
describing the TOETVA learning curve using operative well as the limitations with regards to oncologic outcomes
time as a surrogate concluded that 11 cases were needed for given the lack of long term oncologic follow up. Surgeon-
procedural proficiency, which is similar to the 15 case curve directed ultrasound has a vital role in determining eligibility
described for video-assisted thyroidectomy (47,48). However, as well as in surgical planning in clinic and prior to port
this study represented the learning curve of only one surgeon placement in our practice. Patients should be educated
in a high volume tertiary hospital and may not be germane to about postoperative care including use of antibiotics, wound
other settings. Further data to determine a requisite number care and a suggested set of postoperative exercises to hasten
of open thyroidectomies in order to perform transoral recovery (50).
thyroid surgery is not available (44). The surgeon must also
demonstrate competence with relevant instrumentation and
Intraoperative highlights
advanced laparoscopy in order to avoid novel and/or serious
complications (44). This requires case observations, cadaveric TOETVA surgical developments have been seen in trocar
dissections, and mentored initiation of cases to ensure the placement and intraoperative neuromonitoring (IONM)
safety of this novel procedure (41). In addition to surgeon use. Three incisions are made in the lower vestibule of
familiarity, all operating room staff should be familiar with the mouth. The midline incision is made just above the
the procedure and their respective roles. inferior labial frenulum with a scalpel as preferred by our
group to avoid the risk of lip burn. The other two incisions
are made just medial to the the vermillion border near the
Transoral endoscopic parathyroidectomy vestibular
labial commissure and measures less than 5-mm in length.
approach (TOEPVA)
Chai et al., moved these two incisions lateral/posterior from
TOEPVA can also be performed for select patients with the canine teeth which have been attributed to less mental
localized primary hyperparathyroidism (HPT). Those nerve injury and tearing of the lip commissures (51).
without parathyroid adenoma localization, recurrent or Recently, our group has also detailed the use of IONM
persistent primary HPT, suspected multigland disease, during TOETVA (52). This is performed through a FDA-
secondary or tertiary HPT, family history of MEN, approved, single use, 230 mm monopolar probe with a
suspected parathyroid carcinoma, or previous central neck ball tip, connected to the IONM system. This allows the
surgery or neck irradiation therapy should be excluded surgeon to identify and evaluate the status of the vagus,
from consideration. Similar to TOETVA, the patient recurrent laryngeal, and superior laryngeal nerves without
should also be highly motivated for a “scarless” approach. any additional incisions. IONM allows active monitoring
The authors recommend two imaging modalities with during thyroid retraction and dissection. Moreover, it
concordant findings, usually surgeon performed ultrasound enables ipsilateral RLN evaluation prior to proceeding
and sestamibi with multi-phase CT, for localization prior with contralateral lobectomy during a total thyroidectomy.
to offering TOEPVA. This has shown to have a positive IONM potential limitations associated with use are its costs,
predictive value of up to 99% for localization (49). the need for intraoperative instrument exchange, and probe

412 Russell et al. TOETVA/TOEPVA 2020 update

availability and disposability. Despite this, IONM increases Anuwong et al. (32) reported significant differences in mean
the confidence of surgeons to perform TOETVA safely, and operative times of 78.6 versus 64.2 minutes for lobectomy
is strongly encouraged by our group. via TOETVA and the open approach, respectively, and
For the robotic technique, surgeons may utilize an 135.1 versus 103.3 minutes for total thyroidectomy via
additional axillary incision to insert the fourth robotic TOETVA than the open approach, respectively.
arm for counter-traction and drain insertion if needed. The experience with TOEPVA has been more limited than
Though it is useful, this contradicts the cutaneous “scarless” TOETVA thus far. Sasanakietkul et al.’s 12-patient series from
principle of the transoral surgery that made our group less Thailand demonstrated the safety of the procedure while
enthusiastic about employing the current robotic surgical achieving biochemical cure of primary hyperparathyroidism
systems for the transoral thyroid surgery. without major complications (53). One temporary recurrent
laryngeal neve palsy was reported. Our group has presented
our experience with more than 20 cases (54).
Outcomes, limitations and potential
complications
Potential complications
Outcomes
Novel complications associated with transoral vestibular
Our group has recently performed an analysis to determine approach surgery include mental nerve injury, chin flap
outcomes of 689 TOETVA patients (34) who have undergone perforation, and oral commissure or inferior labial frenulum
isthmusectomy, lobectomy, subtotal thyroidectomy, or total tear. Revised positions of vestibular incisions to decrease
thyroidectomy, with and without central neck dissection. the incidence of nerve injury have been implemented in
Of these 689 cases, 683 (99%) were completed without some series. Previous reports of the transoral vestibular
conversion. Those converted to an open approach were due approach documented a high complication rate (15.6–100%)
to uncontrolled bleeding (five cases) and excessive tumor for mental nerve injury with use of the robotic-assisted
size with evidence of pretracheal nodal metastasis (one case). technique due to the 5 mm incisions in close proximity
No published cases of permanent RLN injury, permanent to the center incisions (16,55,56). Since then, both 5 mm
hypoparathyroidism, CO2 embolism, permanent mental incisions have been relocated, allowing for greater mobility
nerve injury with TOETVA, with only one hematoma (0.1%) of the lip and decreasing tension on the mental nerve where
reported. The transoral approach to the neck is classified as it exits the mental foramen.
‘clean-contaminated’ surgery and carries an inherently greater
risk of infection than clean transcervical thyroidectomy.
However, only one case of neck infection (0.1%) has Discussion and future directions
been reported. Other complications include reported oral Transoral vestibular approach central neck surgery has
commissure tears and three cases (0.4%) of skin flap burn. emerged as a solution for patients who wish to avoid any
Moreover, TOETVA patients had decreased postoperative cutaneous incision (Figure 1). Even as scrutiny of novel
pain compared with patients undergoing transcervical operative techniques and the effects that new technologies have
thyroidectomy in one series (32). No significant difference in on patient outcomes has increased, TOETVA and TOEPVA
length of stay has been described (32). has spread rapidly as an alternative to open thyroidectomy and
other remote-access thyroidectomy techniques.
Still as relatively novel surgical techniques, TOETVA
Limitations
and TOEPVA will likely continue to gain traction as their
Similar to other novel surgical techniques, transoral utilization increases and surgeons become more accustomed
vestibular approach surgery is limited by increased and experienced with the techniques. With increased
operating time, a notable but reasonable learning curve, operative use and surgeon experience with this approach,
unique complications (generally minor, as above), and rigid the gap in conventional outcomes between TOETVA and
patient selection criteria. (TOET/PVA) has significantly the transcervical approach will likely continue to narrow,
longer operative times than the conventional transcervical with both operative time and the incidence of TOETVA-
technique in all described case series, perhaps due to port specific complications diminishing.
placement and flap dissection (43). The largest series by Furthermore, with the development of the new da Vinci

Gland Surgery, Vol 9, No 2 April 2020 413

A B

Figure 1 A 31-year-old woman (A) and a 56-year-old man (B) 3 weeks after TOETVA.

single-port robotic system, additional cutaneous incision may mark the next horizon for surgical operative innovation
for an additional surgical arm may no longer be necessary in the neck.
in robotic surgery. Hence, the transoral vestibular approach
may be further augmented with robotic surgery to achieve
Conclusions
a truly scarless technique that enhances surgical dexterity
and subjective surgical performance without compromising TOET/PVA is the only surgical technique for thyroid and
the improved cosmesis of TOETVA and TOEPVA (57). parathyroid surgery that does not have any cutaneous
Currently, the large size of the central port has limited incision. The rapid adoption to date suggests that further
utilization to some degree. gains may be forthcoming. Future studies are necessary to
With increasing experience and utilization of TOETVA demonstrate the long-term value of the approach.
and TOEPVA may come expanding indications for other
thyroid and parathyroid pathologies. Eligibility criteria for
Acknowledgments
a transoral vestibular approach have continued to expand
to include use in well-differentiated thyroid carcinomas, The authors thank Emerson Lee for technical help and
thyroglossal duct cysts, Graves’ disease, and sex-affirming language editing assistance.
chondrolaryngoplasty. Nevertheless, careful adoption is crucial Funding: None.
for successful implementation as premature implementation
can increase the rate of conversion and hence abandonment of
Footnote
the new technique—and all it has to offer (42).
Although the development and implementation of a Conflicts of Interest: All authors have completed the ICMJE
transoral vestibular approach for these surgeries may have uniform disclosure form (available at http://dx.doi.
high initial costs, the payoffs—potential for increased org/10.21037/gs.2020.03.05). Dr. Tufano reports personal
cosmesis, decreased pain, and improved quality-of-life— fees from Medtronics, personal fees from Hemostatix,

414 Russell et al. TOETVA/TOEPVA 2020 update

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Cite this article as: Russell JO, Sahli ZT, Shaear M, Razavi C,
Ali K, Tufano RP. Transoral thyroid and parathyroid surgery
via the vestibular approach—a 2020 update. Gland Surg
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